J. Sellier

Diagnosis and treatment of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: An overview.

Hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease is an autosomic dominant disorder, which is characterized by the development of multiple arteriovenous malformations in either the skin, mucous membranes, and/or visceral organs. Pulmonary arteriovenous malformations (PAVMs) may either rupture, and lead to life-threatening hemoptysis/hemothorax or be responsible for a right-to-left shunting leading to paradoxical embolism, causing stroke or cerebral abscess. PAVMs patients should systematically be screened as the spontaneous complication rate is high, by reaching almost 50%. Neurological complications rate is considerably higher in patients presenting with diffuse pulmonary involvement. PAVM diagnosis is mainly based upon transthoracic contrast echocardiography and CT scanner examination. The latter also allows the planification of treatments to adopt, which consists of percutaneous embolization, having replaced surgery in most of the cases. The anchor technique consists of percutaneous coil embolization of the afferent pulmonary arteries of the PAVM, by firstly placing a coil into a small afferent arterial branch closely upstream the PAVM. Enhanced contrast CT scanner is the key follow-up examination that depicts the PAVM enlargement, indicating the various mechanisms of PAVM reperfusion. When performed by experienced operators as the prime treatment, percutaneous embolization of PAVMs, is a safe, efficient and sustained therapy in the great majority of HHT patients.

Roles of cyclooxygenase 2 and hepatic venous flow in patients with HHT or hepatopulmonary syndrome

BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) and hepatopulmonary syndrome are disorders characterized by the development of multiple pulmonary arteriovenous malformations (PAVM). PRESENTATION OF THE HYPOTHESIS COX2 may be at the origin of a cascade of pro inflammatory events to favour angiogenesis and PAVM development. TESTING THE HYPOTHESIS HHT and hepatopulmonary syndrome mouse models may be used to show its effects on PAVM formation. Anti COX-2 therapy could also be tested in human individuals, particularly in patients presenting a hepatopulmonary syndrome or HHT with small PAVM. IMPLICATION OF THE HYPOTHESIS PAVMs are one of the main causes of morbidity in patients presenting with HHT disease, owing to the risks of rupture as well as paradoxical embolism exposing to stroke and/or cerebral abscess. Percutaneous embolization has become the treatment of choice of PAVM. Anti COX2 may prevent from PAVM development and subsequent related complications and avoid either surgery and/or percutaneous embolization and thus subsequent related complication.

Place de l’imagerie dans la prise en charge des hémorragies digestives aiguës

RésuméObjectifsÉvaluer la place de l’imagerie diagnostique et interventionnelle dans les hémorragies digestives aiguës hautes et basses (hors rupture de varices d’hypertension portale) en cas d’insuffisance du traitement endoscopique.MéthodesRevue de la littérature des 15 dernières années, se référant à la prise en charge endoscopique, radiologique et chirurgicale des hémorragies digestives aiguës.RésultatsEn raison de son succès (85 à 90 %), le traitement endoscopique est le traitement de première intention. En cas d’échec d’une première endoscopie pour hématémèse, une deuxième doit être tentée, avec si possible le « marquage » du site hémorragique par clip. Dans un second temps, se positionnent l’embolisation et la chirurgie, guidées par l’angioscanner. Les résultats des deux techniques, évalués sur des séries rétrospectives, sont similaires. La population des malades embolisés était, généralement, à haut risque chirurgical en raison de la comorbidité et de la coagulopathie. L’embolisation doit atteindre le site du saignement, occlure l’artère responsable et prendre en compte le caractère anastomotique des territoires digestifs pour prévenir toute récidive. La surveillance post-embolisation doit permettre de dépister précocement d’éventuelles complications ischémiques.ConclusionLe couple angioscanner-embolisation est performant dans la localisation du saignement et le traitement des hémorragies persistantes ou récidivantes après endoscopie thérapeutique. Les évolutions techniques du microcathétérisme ont augmenté l’efficacité thérapeutique de l’embolisation et réduit sa morbidité. L’embolisation a une place prépondérante et doit être privilégiée notamment chez les patients à haut risque chirurgical.AbstractObjectivesTo evaluate the role of diagnosis and interventional radiology in acute upper and lower gastrointestinal bleeding (excluding variceal bleeding) in case of failure of endoscopic treatment.MethodsReview of literature of the past 15 years, referring to the endoscopic, radiological and surgical management in acute gastrointestinal bleeding.ResultsBecause of its success (85–90%), endoscopic treatment confirmed its leading role. When endoscopical first attempt for hematemesis fails, a second one should be attempted, and when possible “tagging” the site with a surgical hemostatic clip. Embolization or surgery are then emphazised and guided by the findings of angio-CT. Their results are similar, in retrospective series, as the population embolized was of high surgical risk due to comorbidity and coagulopathy. Embolization should reach the site of bleeding and close the feeding artery. It should consider the whole anastomosic arterial network, to prevent recurrence. Close post-embolization monitoring should screen ischemic complications.ConclusionThe combination of angio-CT and embolization is successful in targeting and treating persistent or recurrent bleeding after endoscopic management. Technical improvements using microcatheters, increases the embolization’s effectiveness and reduces morbidity. Embolization has a major role and should be preferred in patients with surgical risk.